Anabolic steroids were first isolated, identified and synthesized in the 1930s, and are now used therapeutically in medicine to stimulate bone growth and appetite, induce male puberty, and treat chronic wasting conditions, such as cancer and AIDS. Anabolic steroids also produce increases in muscle mass and physical strength, and are consequently used in sport and bodybuilding to enhance strength or physique. Serious health risks can be produced by long-term use or excessive doses of anabolic steroids. These effects include harmful changes in cholesterol levels (increased bad cholesterol and decreased good cholesterol), acne, high blood pressure, liver damage, and dangerous changes in the structure of the left ventricle of the heart. Some of these effects can be mitigated by exercise, or by taking supplemental drugs.

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Performance enhancing substances have been used for thousands of years in traditional medicine by societies around the world, with the aim of promoting vitality and strength.[2] In particular, the use of steroidhormones pre-dates their identification and isolation: medical use of testicle extract began in the late 19th century, and its effects on strength were also studied then.[3]

This testicular hormone was first identified by Karoly Gyula David, E. Dingemanse, J. Freud and Ernst Laqueur in a May 1935 paper "On Crystalline Male Hormone from Testicles (Testosterone)." They named the hormone testosterone, from the stems of testicle and sterol, and the suffix of ketone. The chemical synthesis of testosterone was achieved in August that year, when Butenandt and G. Hanisch published a paper describing "A Method for Preparing Testosterone from Cholesterol." Only a week later, the third group, Ruzicka and A. Wettstein, announced a patent application in a paper "On the Artificial Preparation of the Testicular Hormone Testosterone (Androsten-3-one-17-ol)." Ruzicka and Butenandt were offered the 1939 Nobel Prize for Chemistry for their work, but the Nazi government forced Butenandt to decline the honor.[4][5]

Clinical trials on humans, involving either oral doses of methyl testosterone or injections of testosterone propionate, began as early as 1937.[4] Testosterone propionate is mentioned in a letter to the editor of Strength and Health magazine in 1938; this is the earliest known reference to an anabolic steroid in a U.S.weightlifting or bodybuilding magazine.

From the 1950s until the 1980s, there were doubts that anabolic steroids produced anything more than a placebo effect. In a 1972 study,[8] participants were informed they would receive injections of anabolic steroids on a daily basis, but instead had actually been given a placebo. They reportedly could not tell the difference, and the perceived performance enhancement was similar to that of subjects taking the real anabolic compounds. According to Geraline Lin, a researcher for the National Institute on Drug Abuse, these results remained unchallenged for 18 years, even though the study used inconsistent controls and insignificant doses.[9] In a 2001 study, the effects of high doses of anabolic steroids were examined, by injecting variable doses (up to 600 mg/week) of testosterone enanthate into muscle tissue for 20 weeks. The results showed a clear increase in muscle mass and decrease in fat mass associated with the testosterone doses.[10]

As the name suggests, anabolic-androgenic steroids have two different, but overlapping, types of effects. First, they are anabolic, meaning that they promote anabolism (cell growth). Some examples of the anabolic effects of these hormones are increased protein synthesis from amino acids, increased appetite, increased bone remodeling and growth, and stimulation of bone marrow, which increases the production of red blood cells.

Through a combination of these effects, anabolic steroids stimulate the formation of muscles and hence cause an increase in the size of muscle fibers, leading to increased muscle mass and strength.[12][13][14] This increase in muscle mass is mostly due to larger skeletal muscles, and is caused by both increased production of muscle proteins as well as a decline in the breakdown rate of these proteins. A high testosterone dose also decreases the amount of fat in muscle, while increasing protein content. Steroids also decrease overall fat.

High doses of oral anabolic steroid compounds can cause liver damage as the steroids are metabolized (17-alpha-alkylated) in the digestive system to increase their bioavailability and stability.[28] When high doses of such steroids are used for long periods, the liver damage may be severe and lead to liver cancer.[29][30]

There are also gender-specific side effects of anabolic steroids. Development of breast tissue in males, a condition called gynecomastia (which is usually caused by high levels of circulating estrogen), may arise because of increased conversion of testosterone to estrogen by the enzyme aromatase.[31] Reduced sexual function and temporary infertility can also occur in males.[32][33][34] Another male-specific side effect which can occur is testicular atrophy, caused by the suppression of natural testosterone levels, which inhibits production of sperm (most of the mass of the testes is developing sperm). This side effect is temporary: the size of the testicles usually returns to normal within a few weeks of discontinuing anabolic steroid use as normal production of sperm resumes.[35] Female-specific side effects include increases in body hair, deepening of the voice, enlarged clitoris, and temporary decreases in menstrual cycles. When taken during pregnancy, anabolic steroids can affect fetal development by causing the development of male features in the female fetus and female features in the male fetus.[36]

A number of severe side effects can occur if adolescents use anabolic steroids. For example, the steroids may prematurely stop the lengthening of bones (premature epiphyseal fusion through increased levels of estrogen metabolites), resulting in stunted growth. Other effects include, but are not limited to, accelerated bone maturation, increased frequency and duration of erections, and premature sexual development. Anabolic steroid use in adolescence is also correlated with poorer attitudes related to health.[37]

The effect of anabolic steroids on muscle mass is caused in at least two ways:[39] first, they increase the production of proteins; second, they reduce recovery time by blocking the effects of stress hormone cortisol on muscle tissue, so that catabolism of muscle is greatly reduced. It has been hypothesized that this reduction in muscle breakdown may occur through anabolic steroids inhibiting the action of other steroid hormones called glucocorticoids that promote the breakdown of muscles.[40] Anabolic steroids also affect the number of cells that develop into fat-storage cells, by favouring cellular differentiation into muscle cells instead.[41]

In the case of anabolic steroids, the receptors involved are called the androgen receptors. The mechanisms of action differ depending on the specific anabolic steroid. Different types of anabolic steroids bind to the androgen receptor with different affinities, depending on their chemical structure. Anabolic steroids such as methandrostenolone bind weakly to this receptor and instead directly affect protein synthesis or glycogenolysis. On the other hand, steroids such as oxandrolone bind tightly to the receptor and act mostly on gene expression.

Growth stimulation: Anabolic steroids were used heavily by pediatric endocrinologists for children with growth failure from the 1960s through the 1980s. Availability of synthetic growth hormone, which has fewer side effects, and increasing social stigmatization of anabolic steroids led to discontinuation of this use.

Induction of male puberty: Androgens are given to many boys distressed about extreme delay of puberty. Testosterone is now nearly the only androgen used for this purpose and has been shown to increase height, weight, and fat-free mass in boys with delayed puberty.[46]

Used to treat gender dysmorphia (the belief that one was born the wrong gender) by producing secondary male characteristics, such as a deeper voice, increased bone and muscle mass, facial hair, increased levels of red blood cells and clitoral enlargement in female-to-male patients.

It is extremely difficult to determine what percent of the population in general have actually used anabolic steroids, but the number seems to be fairly low. Studies have shown anabolic steroid users tend to be mostly middle class heterosexual men with a median age of about 25 who are noncompetitive bodybuilders and non-athletes who use the drugs for cosmetic purposes.[55] According to a recent survey, 78.4% of steroid users were noncompetitive bodybuilders and non-athletes while about 13% reported unsafe injection practices such as reusing needles, sharing needles, and sharing multidose vials.[56] Most users do not compete in any sports. Anabolic steroid users often are stereotyped as uneducated or called "muscle heads" by popular media and culture, however, a 1998 study on steroid users showed them to be the most educated drug users out of all users of controlled substances.[57] Anabolic steroid users also tend to research the drugs they are taking more than any other group of users of controlled substances. Moreover, anabolic steroid users tend to be disillusioned by the portrayal of anabolic steroids as deadly in the media and in politics.[58]

Anabolic steroids have been used by men and women in many different kinds of professional sports (cricket, track and field, weightlifting, bodybuilding, shot put, cycling, baseball, wrestling, mixed martial arts, boxing, football, etc.) to attain a competitive edge or to assist in recovery from injury. Steroids used to obtain competitive advantage are prohibited by the rules of the governing bodies of many sports. Anabolic steroid use seems to occur among adolescents especially by those in sports. It has been suggested that the prevalence of use among high school students in the U.S. may be as high as 2.7%.[59] Male students used more than female students and, on average, those who participated sports used more often than those who did not on average.

A vial of the injectable anabolic steroid, depo-testosterone cypionate

There are three common forms in which anabolic steroids are administered: oral pills, injectable steroids, and skin patches. Oral administration is most convenient, but the steroid must be chemically modified so that the liver cannot break it down before it reaches the blood stream; consequently these formulations can cause liver damage in high doses.[60] Injectable steroids are typically administered into the muscle, not into the vein, to avoid sudden changes in the amount of the drug in the bloodstream. Transdermal patches (adhesive patches placed on the skin) may also be used to deliver a steady dose through the skin and into the bloodstream.

To combat the natural testosterone suppression and to restore proper function of numerous glands involved, what is known as "post-cycle therapy" or PCT is sometimes used. PCT takes place after each cycle of anabolic steroid use and typically consists of a combination of the following drugs, depending on which protocol is used:

The aim of PCT is to return the body's endogenous hormonal balance to its original state within the shortest period of time. People prone to the premature hair loss exacerbated by steroid use have been known to take the prescription drug finasteride for prolonged periods of time. Finasteride reduces the conversion of testosterone to DHT, the latter having much higher potency for alopecia. Finasteride is useless in the cases when steroid is not converted into a more androgenic derivative.[65] Since anabolic steroids can be toxic to the liver or can cause increases in blood pressure or cholesterol, many users consider it ideal to get frequent blood work tests and blood pressure tests to make sure their blood pressure or cholesterol are still within normal levels.

Anabolic steroids, like many other drugs, have generated much controversy. There are also many popular misconceptions concerning their effects and side effects. One common misconception in popular culture and the media is that anabolic steroids are highly dangerous and users' mortality rates are high. Anabolic steroids are used widely in medicine with an acceptable side-effect profile, so long as patients are monitored for possible complications.[66][67][68][69] As with all drugs, anabolic steroids do have side effects, but the risk of premature death from the use of anabolic steroids seems to be extremely low.[69][66][70] Former assistant professor at the University of TorontoMauro Di Pasquale has stated, "As used by most people, including athletes, the adverse effects of anabolic steroids appear to be minimal."[71]

One possible origin of the idea that steroids are extremely dangerous is from claims that Lyle Alzado died from brain cancer caused by anabolic steroids. Indeed, Alzado himself claimed that anabolic steroids were the cause of his cancer.[72] However, although steroids can cause liver cancer,[73] there is no published evidence that anabolic steroids cause either brain cancer or the specific type of T-cell lymphoma that caused his death.[74][72] Alzado's doctors stated that anabolic steroids did not contribute to his death.[75]

Another example is the misconception that anabolic steroids can shrink the male penis. It is possible that this idea came from temporary side effect that anabolic steroids have on testicle size (testicular atrophy), discussed previously.

Other purported side effects include the idea that anabolic steroids have caused many teenagers to commit suicide.[76] While lower levels of testosterone have been known to cause depression, and ending a steroid cycle temporarily lowers testosterone levels, the hypothesis that anabolic steroids are responsible for suicides among teenagers remains unproven. Although teen bodybuilders have been using steroids since at least the early 1960s, only a few cases suggesting a link between steroids and suicide have been reported in the medical literature.[77]

Another condition that is frequently discussed as a possible side effect of anabolic steroids is known as "roid rage"; however there is no consensus in the medical literature as to whether such a condition actually exists. Testosterone levels are indeed associated with aggression and hypomania, but the link between other anabolic steroids and aggression remains unclear.[78] While some studies have shown a correlation between manic symptoms and anabolic steroid use,[79] later studies have questioned these conclusions.[70] Currently, three blind studies have demonstrated a link between aggression and steroid use, but with estimates of over 1 million past or current steroid users in the United states, an extremely small percentage of those using steroids appear to have experienced mental disturbance severe enough to result in clinical treatments or medical case reports.[80] Individual studies vary in their findings, with some reporting no increase in aggression or hostility with anabolic steroid use, and others finding a correlation.[81][82] Including a study of two pairs of identical twins, in which one twin used anabolic steroids and the other did not, found that in both cases the steroid-using twin exhibited high levels of aggressiveness, hostility, anxiety and paranoid ideation not found in the "control" twin.[83]

It has previously been theorized that some studies showing a correlation between angry behavior and steroid use are confounded by the fact that steroid users are likely to demonstrate cluster B personality disorders prior to administering steroids.[84] In addition, many case studies have concluded anabolic steroids have little or no real effect on increased aggressive behavior.[85][66][86][87]

Arnold Schwarzenegger is the subject of an urban legend regarding the side effects of anabolic steroids. Schwarzenegger has admitted to using anabolic steroids during his bodybuilding career for many years prior to them being made illegal,[88] and in 1997 he underwent surgery to correct a defect relating to his heart. Some have assumed this was due to anabolic steroids. Although anabolic steroid use can sometimes cause unfavorable enlargement and thickening of the left ventricle, Schwarzenegger was born with a congenital genetic defect in which his heart had a bicuspid aortic valve — in other words, whereas normal hearts have three cusps, his had only two, which can occasionally cause problems later in life.[89]

The legal status of anabolic steroids varies from country to country: some have stricter controls on their use or presciption than others. In the U.S., anabolic steroids are currently listed as Schedule III controlled substances under the Controlled Substances Act, which makes the possession of such substances without a prescription a federal crime punishable by up to seven years in prison.[90] In Canada, anabolic steroids and their derivatives are part of the Controlled drugs and substances act and are Schedule IV substances, meaning that it is illegal to obtain or sell them without a prescription; however, possession is not punishable, a consequence reserved for schedule I, II or III substances. Those guilty of buying or selling anabolic steroids in Canada can be imprisoned for up to 18 months. Import and export also carry similar penalties.[91] Anabolic steroids are also illegal without prescription in Australia,[92]Argentina, Brazil and Portugal,[93] and are listed as Schedule 4 Controlled Drugs in the United Kingdom. On the other hand, anabolic steroids are readily available without a prescription in countries such as Mexico and Thailand.

The history of the U.S. legislation on anabolic steroids goes back to the late 1980s, when the U.S. Congress considered placing anabolic steroids under the Controlled Substances Act following the controversy over Ben Johnson's victory at the 1988 Summer Olympics in Seoul. During deliberations, the AMA, DEA, FDA as well as the NIDA all opposed listing anabolic steroids as controlled substances, citing the fact that use of these hormones does not lead to the physical or psychological dependence required for such scheduling under the Controlled Substance Act. Nevertheless, anabolic steroids were added to Schedule III of the Controlled Substances Act in the Anabolic Steroid Control Act of 1990.[94] The same act also introduced more stringent controls with higher criminal penalties for offenses involving the illegal distribution of anabolic steroids and human growth hormone. By the early 1990s after anabolic steroids were scheduled in the U.S., several pharmaceutical companies stopped manufacturing or marketing the products in the U.S., including Ciba, Searle, Syntex and others.

In the Controlled Substances Act, anabolic steroids are defined to be any drug or hormonal substance chemically and pharmacologically related to testosterone (other than estrogens, progestins, and corticosteroids) that promote muscle growth. The act was amended by the Anabolic Steroid Control Act of 2004, which added prohormones to the list of controlled substances, with effect from January 20, 2005.[90]

Anabolic steroids are banned by all major sports bodies including the Olympics,[95] the NBA,[96] the NHL,[97] as well as the NFL.[98] The World Anti-Doping Agency (WADA) maintains the list of performance-enhancing substances used by many major sports bodies and includes all anabolic agents, which includes all anabolic steroids and precursors as well as all hormones and related substances.[99][100]Spain has passed an anti-doping law which would create a national anti-doping agency.[101]Italy passed a law in 2000 where penalties range up to three years in prison if an athlete has tested positive for banned substances.[102] In 2006, Russian President Vladimir Putin signed into law ratification of the International Convention Against Doping in Sport which would encourage cooperation with WADA. Many other countries have similar legislation prohibiting anabolic steroids in sports including Denmark,[103]France,[104] the Netherlands[105] and Sweden.[106]

In countries where anabolic steroids are illegal or controlled, the majority of steroids are obtained illegally through black market trade.[107][108] These steroids are usually manufactured in other countries, and therefore must be smuggled across international borders. Like most significant smuggling operations, organized crime is involved. Smuggling of anabolic steroids often occurs in conjunction with other illegal drugs, although in comparison with the trade in psychoactiverecreational drugs such as cannabis and heroin, there have not been many high profile cases of individual smugglers of anabolic steroids being caught.

In addition to smuggling, illegal trade in counterfeit drugs has emerged rapidly in recent years, as computers and scanning technology have made it easy to copy the label design of genuine products. Consequently, the market has been flooded with products containing anything from vegetable oil to toxic substances. These products have been bought and injected by unsuspecting users, some of whom have died as a result of blood poisoning, methanol poisoning, or subcutaneous abscess.[109]

Anabolic steroids need sophisticated pharmaceutical processes and equipment to produce, so they are either manufactured by legitimate pharmaceutical companies or by underground laboratories with large overheads. Common problems associated with illegal drug trades, such as chemical substitutions, cutting, and diluting, affect illegal anabolic steroids as well, so that when they reach the distribution level, the quality may be compromised and the drugs may be dangerous. In the 1990s, most U.S. producers such as Ciba, Searle and Syntex stopped making and marketing anabolic steroids within the U.S. However, in many other regions, particularly Eastern Europe, they are still produced in quantity. European anabolic steroids are the source of most medical grade anabolic steroids sold illegally in North America. However, anabolic steroids are still in wider use for veterinary purposes, and many illegal anabolic steroids are actually veterinary grade.[110] These can also be dangerous, as they may have been produced and handled in cruder and less sterile environments.[111][112]

In the U.S., Canada and Europe, steroids are purchased just like any other illegal drug, through dealers who are able to obtain the drugs from a number of sources. Most users would prefer to buy from legitimate sources but cannot because of the legal restrictions. Instead, illegal anabolic steroids are sold at gyms, competitions, and through the mail. For the most part, these substances are smuggled, but may also be obtained through pharmacists, veterinarians, and physicians. In addition, a significant number of counterfeit products are sold as anabolic steroids, particularly via mail order from websites posing as overseas pharmacies. Individuals also produce fake steroids and attempt to sell them over the Internet, causing a wide variety of health concerns. In the U.S., black market importation continues from Mexico, Thailand, and other countries where steroids are more easily available or not illegal at all.

After the Anabolic Steroid Control Act of 1990 listed anabolic steroids as Schedule III controlled substances in the U.S., a small movement has arisen that is highly critical of current laws concerning anabolic steroids. On June 21, 2005, Real Sports aired a segment discussing the legality and prohibition of anabolic steroids in America.[113] The show featured Gary I. Wadler, M.D., chairman of the U.S. Anti-Doping Agency and a prominent anti-steroid activist. When pressed for scientific evidence by correspondent Armen Keteyian that anabolic steroids are as "highly fatal" as is often claimed, Wadler admitted there was no evidence. Gumbel concluded the "hoopla" concerning the dangers of anabolic steroids in the media was "all smoke and no fire". The show also featured John Romano, a pro-steroid activist who writes "The Romano Factor", a pro-steroid column for bodybuilding magazine Muscular Development.

In July 2005, Philip Sweitzer, an attorney and author, published an open letter to the Members of the House Committee on Government Reform, and the Senate Committee on Commerce et al. In it he criticized lawmakers' actions in scheduling anabolic steroids, as well as criticized their "disregard of scientific reality for symbolic effect". He also pleaded for the consideration of the decriminalization of anabolic steroids and asked for a new policy direction.[114] Several other legal reviewers have criticized controlled substance status for anabolic steroids, including lawyer Rick Collins whose book, Legal Muscle, details published resources on anabolic steroids and the law. Collins opposes non-medical teen steroid use or steroid use to cheat in sports, but advocates wider discretion for physicians in the case of mature adults. In 2006, he argued at PUMPED, a steroid seminar in Manhattan, that the reporting of the risks associated with anabolic steroids in the media is biased and misinformed. He also argues that anabolic steroid criminalization increases the risks associated with anabolic steroids due to impurities in black market products.[115][116] However, the U.S. government's position since the late 1980s has been and continues to be that the risks of steroid use are too great to allow them to be decriminalized or unregulated.